1A SPRUANCE WAY - BUILDING INSPECTION �`ZScP\S* ,�
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The Commonwealth chma�§ t6le s
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Department of Public Safety
MassachusettsState Buildin C,� 7f0.1 M[� A � 45
Building Permit Application for any Building other4Tl a�ne-or Two-Family Dwelling
(This Section For Official Use Only)
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Building Permit Number: Date Applied: /S=JIa Buildingofficial:
SECTION 1:LOCATION(Please indicate Block#and Lot#for locations for which a street address is not available)
t/1 S�orF�li sf 4 0/; 9-r ��q7o yrct�,u�cac P9eK
^ No.and Street City/Town Zip Code Name of Building(if applicable)
SECTION 2:PROPOSED WORK
Edition of NIA State Code used_ If New Construction check here❑or check all that apply in the two rows below
Existing Building❑ Repair❑ Alteration ❑ Addition❑ Demolition ❑ (Please fill out and submit Appendix l)
Change of Use ❑ Change of Occupancy ❑ Other ❑ Specify:
Are building plans and/or construction documents being supplied as part of this permit application? Yes ❑ No a,—
Is an Independent Structural Engineering Peer Review required? Yes ❑ No ❑
Brief Description of Proposed Work:. o k
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_ /2 G -z r
SECTION 3:COMPLETE THIS SECTION IF EXISTING BUILDING UNDERGOING RENOVATION,ADDITION,OR
CHANGE IN USE OR OCCUPANCY
Check here if an Existing Building Investigation and Evaluation is enclosed(See 780 CMR 31) ❑
Existing Use Group(s): Proposed Use Group(s):
SECTION 4:BUILDING HEIGHT AND AREA
Existing Proposed
\ / No.of Floors/Stories(include basement levels)dr Area Per Floor(sq.ft.)
X Total Area(sq.ft.)and Total Height(ft.) &2,5 1 g/f- S
SECTION 5:USE GROUP(Check as applicable)
A: Assembly Ad❑ A-2❑ Nightclub ❑ A-3 ❑ A4❑ A\ 5❑ I B: Business ❑ E: Educational ❑
F: Facto F-1 ❑ F2❑ H: Hi h Hazard H-1❑ H-2❑ H-3 ❑ H-4 ClH-5❑
L• Institutional f-1❑ I-2❑ 1-3❑ 1-4❑ M: Mercantile❑ R: Residential R-113 R-2❑ R-3❑ R4 FY
S: Storage S-1 ❑ S-2❑ U: Utility❑ Special Use❑and please describe below:
Special Use:
SECTION 6:CONSTRUCTION TYPE(Check as a licable) / -
fA ❑ 10 ❑ IIA ❑ 110 ❑ ILIA ❑ IfIB ❑ IV ❑ VA Q- VB ❑
SECTION 7:SITE INFORMATION(refer to 780 CMR 111.0 for details on each item)
Water Supplj Flood Zone Information: Sewage Disposal: Trench Permit: Debris Removal:
Public ID Check if outside Flood Zone❑ Indicate municipal❑ A trench will not be Licensed Disposal Site
Private❑ or indentify Zone: or on site system❑ required❑or trench or specify:/9&__1&
permit is enclosed❑ IFVewhf,,
Railroad right-of-way: _ Hazards to,\ir Navigation: r :...:
Not Applicable Is Structure within airport a_pp/ranch area? Is their review completed?
or Consent to Build enclosed❑ Yes❑ or No ur Yes❑ No ❑
SECTIONS:CONTENT OF CERTIFICATE OF OCCUPANCY
I'dition of Code: Use Group(s):_ Type of Construction:_ Occupant Load per Floor:. _
Does the building contain an Sprinkler Sys tern?: _ Special Slipu let ions:
CX� UG:D � SIN T' o 0 1 L 122
SECTION 9: PROPERTY OWNER AUTHORIZATION
Name and Address of Property Owner
IhAW /A_SG.e1. Ildce Sf- Q) t 9-10
Name(Print) Nu.and Street - City/Town Zip
Property Owner Cuniadinfonnatlow,,r, 7
f7CuNF!L t i - B l�9 If79
Title Telephone No.(business) Telephone No. (cell) e-mail address
If applicable,the property owner hereby authorizes
Name Street Address City/Town State Zip
to act on the property owners behalf, in all matters relative to work authorized by this building permit application.
SECTION 10:CONSTRUCTION CONTROL(Please fill out Appendix 2)
If building is less than 35,000 cu.R.of enclosed space and or not under Construction Control then check here O and skip Section 10.1
10.1 Registered Professional Responsible for Construction Control --
Name(Registrant) Telephone No. e-mail address Registration Number
Street Address City/Town State Zip Discipline Expiration Date
10.2 General Contractor
AKeylmll Z.a-de/��ac.uf �JMD �Et2SI3
Company Name _
IDI AJ0 FeT-Cst AV I�eiY!/irv(r
Name bf Person Responsible for Construction License No. and Type if Applicable
J 7 lJ7Lur/n/ S f Glit9C�e`iWAO i -al �ao
Street Address City/Town State Zip
Telephone No. business Telephone No. cell a-mail address
SECTION 11:\V0RKER9'COt,IPFNSA I ION INSUItAaNC1;AFFIDAW1 M.G.L.c.152.§25C 6
A Workers'Compensation Insurance Affidavit from the MA Department of industrial Accidents must be completed and
submitted with this application. Failure to provide this affidavit will result in the denial of the issuance of the building permit.
Is a signed Affidavit submitted with this application? Yes❑ No O
SECTION 12 CONSTRUCTION COSTS AND PERMIT FEE
Estimated Costs:(Labor �/ ee
Item '
and Materials) total Construction Cost(from Item 6)_$ 01 b0
1. Budding $ 2 OD o
Building Permit Fee=Total Construction Cost x_(Insert here
2.Electrical $ appropriate municipal factor)_$
3, Plumbing $
d. Mechanical (HVAC) $ Note:Nlininuun fee=5 (contact municipality)
5.Nlechanical Other $ Enclose check payable to
70® °" y;
6.Total Cost $ � (contact municipality)and write check number here
SECTION 13:SIGNATURE OF BUILDING PERMIT APPLICANT
By entering my name below, I hereby attest under the pains and penalties of perjury that all of the information contained in this
application is true and accurate I the best of my knowledge and understanding.
7�1�oG �� x � J l� �'
Please runt and sign name Title Telephone No. Date
Street Address City/Town State Zip
Municipal Inspector to fill out this section upon application approvat:
Name Date
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The Commonwealth of Massachusetts
Department of Industrial Accidents
%!rkers'
1 Congress Street, Suite 100
Boston, MA 02114-2017
www.mass.gov/dia
Compensation Insurance Affidavit:Builders/Contractors/Electricians/Plumbers.
TO BE FILED WITH THE PERMITTING AUTHORITY.
Applicant Information Please Print Legibav
Name (Business/Organization/Individual):
Address:// ��SO��t'/
City/State/Zip: IV 0 Phone#: �Z� G
Are you an employer?Check the appropriate box:
Type of project(required):
1.❑I am a employer with employees(full and/or part-time).* 7. ❑New construction
2.� am a sole proprietor or partnership and have no employees working for me in g, emodeling
.. any capacity.[No workers'comp.insurance required.]
3.❑I am a homeowner doing all work myself[No workers'camp.insurance required.]1 9. El Demolition
4.❑I am a homeowner and will be hiring contractors toconduct all work on my property. I will 10 ❑ Building addition
ensure that all contractors either have workers'compensation insurance or are sole 1 L❑Electrical repairs Or additions
proprietors with no employees.
12.El Plumbing repairs or additions
5.❑I am a general contractor and I have hired the sub-contractors listed on the attached sheet ]3.❑ROOf repairs
These sub-contractors have employees and have workers'comp.insurance.=
6.❑We are a corporation and its officers have exercised their right of exemption per MGL a 14.❑Other
152,§1(4),and we have no employees.[No workers'camp.insurance required.]
*Any applicant that checks box#1 must also fill out the section below showing their workers'compensation policy information.
t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such.
tContractors that check this box must attached an additional sheet showing the name of the sub-contractors and state whether or not those entities have
employees. If the sub-contractors have employees,they must provide their workers'comp.policy number.
turn an employer that is providing workers'compensation insurance for my employees. Below is the policy and job site
information.
Insurance Company Name:
Policy#or Self-ins.Lic.#: Expiration Date:
Job Site Address: City/State/Zip:
Attach a copy of the workers' compensation policy declaration page(showing the policy number and expiration date).
Failure to secure Coverage as required under MGL c. 152,§25A is a criminal violation punishable by a fine up to$1,500.00
and/or one-year imprisonment,as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to$250.00 a
day against the violator.A copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance
coverage verification.
Ida hereby certify un er the pains aannAd pena'ltites ofperjury that the information provided above is true and correct.
Signature: / /L/G�'�/ Date: 7 fl`7-�IS
Phone#: d-217 107' 6ZOC-
Official use only. Do not write in this area,to be completed by city or town official.
City or Town: Permit/License#
Issuing Authority(circle one):
1.Board of Health 2.Building Department 3.City/Town Clerk 4.Electrical Inspector 5.Plumbing Inspector
6.Other
Contact Person: Phone#:
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Information and Instructions
Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees.
Pursuant to this statute,an employee is defined as"...every person in the service of another under any contract of hire,
express or implied,oral or written."
An employer is defined as"an individual,partnership,association,corporation or other legal entity,or any two or more
of the foregoing engaged in a joint enterprise,and including the legal representatives of a deceased employer,or the
receiver or trustee of an individual,partnership,association or other legal entity,employing employees. However the
owner of a dwelling house having not more than three apartments and who resides therein,or the occupant of the
dwelling house of another who employs persons to do maintenance,construction or repair work on such dwelling house
or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer."
MGL chapter 152,§25C(6)also states that"every state or local licensing agency shall withhold the issuance or
renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any
applicant who has not produced acceptable evidence of compliance with the insurance coverage required."
Additionally,MGL chapter 152, §25C(7)states"Neither the commonwealth nor any of its political subdivisions shall
enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance
requirements of this chapter have been presented to the contracting authority."
Applicants
Please fill out the workers'compensation affidavit completely,by checking the boxes that apply to your situation and,if
necessary,supply sub-contractor(s)name(s),address(es)and phone number(s)along with their certificate(s)of
insurance. Limited Liability Companies(LLC)or Limited Liability Partnerships(LLP)with no employees other than the
members or partners,are not required to carry workers'compensation insurance. If an LLC or LLP does have
employees,a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial
Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should
be returned to the city or town that the application for the permit or license is being requested,not the Department of
Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers'
compensation policy,please call the Department at the number listed below. Self-insured companies should enter their
self-insurance license number on the appropriate line.
City or Town Officials
Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom
of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant.
Please be sure to fill in the permit/license number which will be used as a reference number. In addition,an applicant
that must submit multiple permit/license applications in any given year,need only submit one affidavit indicating current
policy information(if necessary)and under"Job Site Address"the applicant should write"all locations in (city or
town)."A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the
applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each
year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture
(i.e.a dog license or permit to burn leaves etc.)said person is NOT required to complete this affidavit.
The Department's address,telephone and fax number:
The Commonwealth of Massachusetts
Department of Industrial Accidents
1 Congress Street, Suite 100
Boston, MA 02114-2017
Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE
Fax# 617-727-7749
Revised 02-23-15 www.mass.gov/dia
a American Properties Team, Inc.
TO: I Spruance Way
FROM: Jennifer Pappas, Property Manager
RE: Deck Replacement
DATE: April 13, 2015
Please be advised that the Board of Trustees for Pickman Park has approved the replacement of
the deck at the above referenced unit. This approval is contingent upon it matching the existing
deck (composite materials can be used) and following the Engineering Alliance Deck
Specifications. The Board will not allow any design alterations.
We also require that permits be pulled in advance (regardless of what your contractor may tell
you), and then a copy of the final approved permit once completed must be sent to APT for the
unit file as well.
You will need to bring a copy of this letter to the Salem Building Department in order to receive
your permit.
Should you have any questions or require additional information, please feel free to call the APT
Service Team at(781)932-9229.
cc: Unit File
500 WEST CUMMINGS PARK-SUITE 6050. WOBURN -MA 01801 781-932-9229 -FAX 781-935-4289
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QTY OF SALEK MASSAaiUSE M
7 BU1WjNG DEPARTMENT
ck_ 120 WASHINGTONS7REET,3"DFLOOR
-� TEL.(978)745-9595
KIMBERLEYDRISGOLL FAX(978)740-9846
MAYOR THomm STj)mRRE
DIRECTOR OF PM1JCFROFERTY/BUa D1NG O0MIWgSSIONER
Construction Debris Disposal Affidavit
(required for all demolition and renovation work)
In accordance with the sixth edition of the State Building Code, 780 CMR, Section 111.5 Debris,
and the provisions of MGL c40, S 54; Building Permit# is issued with the
condition that the debris resulting from this work shall be disposed of in a properly licensed
waste deposit facility as defined by MGL c 111, S 150A.
The debris will be transported by:
(name of hauler)
The debris will be disposed of in:
(name of facility)
—R7— /A
(address of facility)
Signature of applicant
Date
Massachusetts -Department of Public Safety
Board of Building Regulations and Standards
Construction Supervisor
License: CS-055513 ^'
DINO R PERSIA
11 BABSON S7E 0
Wakefield MA Of$SO
Expiration
Commissioner 07/05/2018
roue�rluch
any use S
Unrestricted 13 Admgs°f i fee,(991m
s '1°f
cAnain less than 35,000 cub
enclosed space*
Massachusetts
edltionotthe ofthislicense,
Failure to P°ssess
a se or
State Building
Code is taus Www pnass.G°vIOPS
pot DpS licensing information visit.